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ABDOMINAL IMAGING Table of Contents   
Year : 2002  |  Volume : 12  |  Issue : 3  |  Page : 353-354
Pancreatic pseudocyst of the mediastinum


Dept of Radiology, Lady Harding Medical College, New Delhi, India

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Keywords: Pseudocyst. Mediastinal mass

How to cite this article:
Mathew M, Narula M K, Anand R. Pancreatic pseudocyst of the mediastinum. Indian J Radiol Imaging 2002;12:353-4

How to cite this URL:
Mathew M, Narula M K, Anand R. Pancreatic pseudocyst of the mediastinum. Indian J Radiol Imaging [serial online] 2002 [cited 2020 Aug 8];12:353-4. Available from: http://www.ijri.org/text.asp?2002/12/3/353/28480

   Introduction Top


Extension of the pancreatic pseudocyst into the posterior mediastinum is uncommon and is fraught with serious complications. Although the cyst is intra-abdominal in origin, the signs and symptoms are due to intra-thoracic extension. Clinical presentation is therefore misleading and a correct diagnosis is a must for instituting appropriate management. We report one such case.


   Case Report Top


A fifty year old male patient was admitted with cough, dysphagia and pyrexia for a week prior to admission. He was a chronic alcoholic and gave no history of abdominal pain, vomiting or previous hospitalization. On clinical examination, he was febrile, with decreased breath sounds in both lung bases. Laboratory investigations revealed leucocytosis and raised serum amylase levels of 542 U/dl.

Chest X-ray (PA view) showed bilateral pleural effusion. Barium swallow study revealed mild displacement of the upper thoracic esophagus with few tertiary contractions. There was a smooth extrinsic impression on the lesser curvature of the stomach with anterior displacement of the fundus and body.

Ultrasound abdomen showed a mildly enlarged pancreas with ill-defined tissue planes. A cystic area of 10x12 mm was seen in the body of the pancreas which was continuous with another cystic area 6x7 cm lying anterior to the body and tail [Figure - 1]. Another fluid collection (9x3 cm) was seen in the lesser sac region.

Computed Tomography confirmed the ultrasound findings and also revealed extension of the fluid collection into the posterior mediastinum, lying postero-lateral to the esophagus and reaching upto the root of the neck on the right side [Figure - 2],[Figure - 3],[Figure - 4]. Based on the CT findings, a diagnosis of acute pancreatitis with pseudocyst and it's extension into the mediastinum was made.

As the patient improved on conservative management, no surgical drainage procedure was contemplated. A repeat CT scan showed significant reduction in the size of the pseudocyst. The patient was discharged after three weeks of admission by which time his serum amylase levels had fallen to 114u/dl.


   Discussion Top


The most common complication of acute pancreatis is the formation of a pseudocyst, which is said to occur in 10-20% of patients. A pseudocyst is a collection of pancreatic secretions, blood and cellular debris which often breaks through the pancreatic capsule. The most common site of involvement is the lesser sac. However, an enlarging pseudocyst dissects along the planes of least resistance and may extend through anatomically preformed points of passage such as the aortic and esophageal hiatus [1] or more rarely, the foramen of Morgagni [2]. It can also spread through erosion of the diaphragm itself [3].

The common findings on chest X-ray are a posterior mediastinal mass with bilateral or left-sided pleural effusion. A typical though not specific radiological finding is anterior and lateral displacement of the lower thoracic esophagus on barium study [4]. Despite this, the patients often do not present with dysphagia. The present case complained of dysphagia, with displacement of the upper thoracic esophagus but there was no displacement of the distal esophagus. Ultrasonography is a very useful investigation for diagnosing pancreatic pseudocysts and delineating their extent. Owing to the difficulty of scanning beneath the sternum, ultrasound may not be able to demonstrate the superior extent of the mediastinal extension [5]. A CT scan however, easily demonstrates the extension into the posterior mediastinum. In the present case, the extension was seen into the posterior mediastinum, extending from the posterior and superior aspect of the pancreas and reaching upto the root of the neck. These findings are better demonstrated on sagittal and coronal reconstruction as in the present case [6]. Endoscopic pancreatography is useful in demonstrating an internal pancreatic fistula preoperatively [7]. However, in our case it was not done owing to the risk of introducing infection and because the patient was improving on conservative management. The differential diagnosis of pseudocyst includes paraspinal abscess, mediastinitis and mediastinal abscess. The clinical presentation, features of acute pancreatitis with pseudocyst on ultrasound and CT, raised serum amylase and demonstration of mediastinal extension on CT scan helped to clinch the diagnosis.

 
   References Top

1.Banks PA, Mc Lellan PA, Gerz SG, Splane EF, Lintz RM, Brown ND. Mediastinal pancreatic pseudocyst. Dig Dis Sci 1984; 29: 664-668.  Back to cited text no. 1    
2.Furst H, Schmittenbecher PP, Dieneman H, Berger H. Mediastinal pancreatic pseudocyst. Eur J Cardiothorac Surg 1992; 6: 46-48.  Back to cited text no. 2    
3.Jaffe BM, Ferguson TB, Holtz S, Shields JB. Mediastinal pancreatic pseudocysts. Am J Surg 1972; 124: 600-606.  Back to cited text no. 3    
4.Kirchner SG, Heller RM, Smith CW. Pancreatic pseudocyst of the mediastinum. Radiology 1977; 123: 37-42.  Back to cited text no. 4    
5.Weinfield A, Kaplan JO, Mediastinal pancreatic pseudocyst. Gastrointest Radiol 1979;4: 343-347.  Back to cited text no. 5    
6.Johnston RH, Owensby LC, Vargas GM, Gacia-Rinaldi R. Pancreatic pseudocyst of the mediastinum. Ann Thorac Surg 1986; 41: 210-212.  Back to cited text no. 6    
7.Heiss FW, Shea JA, Cady B, Scholz FJ. Pancreatic pseudocyst with mediastinal extension and pleural effusion - Demonstration of pathologic anatomy by endoscopic pancreatography. Dig Dis Sci 1979; 24:649-651  Back to cited text no. 7    

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Correspondence Address:
M Mathew
C/o. MK Narula, J13/42, New Delhi
India
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    Figures

[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4]

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    Introduction
    Case Report
    Discussion
    References
    Article Figures

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